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Esophageal Diverticula Esophageal Diverticula Occur in three main areas Occur in three main areas –Zenker’s diverticulum Most common location Most common location –Traction diverticulum Near esophageal midpoint Near esophageal midpoint –Epiphrenic diverticulum Above the LES Above the LES

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Hiatal Hernia Herniation of portion of the stomach into esophagus through an opening or hiatus in diaphragm Herniation of portion of the stomach into esophagus through an opening or hiatus in diaphragm

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Hiatal Hernia Clinical Manifestations May be asymptomatic May be asymptomatic Symptoms include Symptoms include –Heartburn After meal or lying supine After meal or lying supine –Dysphagia

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Hiatal Hernia Surgical Therapy Laparoscopically performed Nissen and Toupet techniques are standard antireflux surgeries Laparoscopically performed Nissen and Toupet techniques are standard antireflux surgeries Thoracic or open abdominal approach used in select cases Thoracic or open abdominal approach used in select cases

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Esophageal Cancer Etiology and Pathophysiology Majority of tumors located in middle and lower portion of esophagus Majority of tumors located in middle and lower portion of esophagus Malignant tumor Malignant tumor –Usually appears as ulcerated lesion –Obstruction in later stages

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Esophageal Cancer Surgical procedures Surgical procedures –Esophagectomy Removal of part or all of the esophagus Removal of part or all of the esophagus –Esophagogastrostomy Resection of a portion of esophagus and anastomosis of remaining portion to stomach Resection of a portion of esophagus and anastomosis of remaining portion to stomach

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Chemoradiation Additional 69 patients were treated with the same combined therapy and were analyzed. Additional 69 patients were treated with the same combined therapy and were analyzed. Similar results were obtained Similar results were obtained –Median survival : 17.2 months –3-year survival : 30% –5 yr survival :14%

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Extensive NODULAR filling defects in the esophagus in an immunocompromised patient are typical for candida esophagitis. Extensive NODULAR filling defects in the esophagus in an immunocompromised patient are typical for candida esophagitis. CANDIDA ESOPHAGITIS

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Barium filled esophagus ACHALASIA Distended esophagus with distal stricture due to Achalasia - Failure of lower sphincter to relax – causing obstruction. Etiology is unknown. BIRD BEAK APPEARANCE Stricture due to cancer or reflux caused scarring have to be considered first.

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Esophagus shows a linear tear of mucosa of distal esophagus due to vomiting with barium tracking into the wall. Full thickness tear or rupture (Boerhaave’s syndrome) can lead to mediastinitis and death. MALLORY-WEISS TEAR

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Proximal loops are dilated and distal loops are collapsed indicating an obstruction. Obstruction most likely due to adhesions in a patient with history of abdominal surgery ZONE OF TRANSISITON CT - SMALL BOWEL OBSTRUCTION PROXIMAL DILATED BOWEL DISTAL NORMAL BOWEL

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HERNIA SM. BOWEL BARIUM STUDY CT Note hernia in right lower quadrant on both exams accounting for obstruction. Hernia is likely cause if there is no history of prior surgery.

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POST – OP ADYNAMIC ILEUS LARGE AND SMALL BOWEL SYMMETRIC dilatation of large and small bowel is seen normally as a post operative ileus. COLON SM. BOWEL

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NORMAL GAS PATTERN AIR UNDER THE DIAPHRAGM Perforation of GI tract leads to pneumoperitoneum collecting subdiaphragmaticly on upright x-ray

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ERECT AND DECUBITUS ABDOMEN FILMS SHOW FREE AIR UNDER THE DIAPHRAGM. DECUBITUS UPRIGHT LEFT LATERAL DECUBITUS (left side dependent) shows air along liver margin. This is the preferred x- ray if the patient cannot stand.

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Rigler’s Sign – See both sides of the bowel wall. Triangle Sign – Small triangles of air